Selective Dorsal Rhizotomy

Selective dorsal Rhizotomy - a life-changing operation.

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700,000 children are born in Germany each year. 1400 of these children suffer infantile cerebral palsy, often without limiting their intelligence but with a lifelong movement disorder. The most common such disorder consists in an increase in muscle tension or spasticity. In 400 - 500 children, their legs are especially affected. Currently, there are between 7000 and 8000 children and adolescents under 18 affected by this particular condition.

Symptoms

  • Severe Gait Disorder
  • The upper thigh is angled, bent and turned inward.
  • The ankle and foot are mostly in tip toe position ("tip toe gait")
  • The spinal column often develops a high-grade curvature (scoliosis).
  • Coordination and balance problems, speech disorders and muscle tremors are possible.

Due to the movement disorders, these children often fall. They often require the use of a wheelchair. Epileptic seizures, hearing and speech disorders can negatively impact their participation in social life. Both the physical and cognitive limitations can hinder their independence and how they deal with day-to-day life, especially in school.

For children and adolescents with infantile cerebral palsy who turn to the Center for Social Pediatrics at Charité Hospital, the independent pediatric neurosurgery division is the first in Germany to offer an operation which leads to long-term improvement the likes of which could not be achieved before.


In close cooperation with Prof. T.S. Park of St. Louis Children's Hospital in Missouri which currently performs 175 rhizotomies per year, the head pediatric neurosurgeon Dr. med. Hannes Haberl has established the method of microscopic selective dorsal rhizotomy established there at Charité Hospital. Its success goes far beyond the results of the previously performed combination of conservative treatment and orthopedic procedures.

  • This procedure considerably improves the ability to stand and walk.
  • It lessens the pain in the large joints caused by spasticity. If performed early, it can decrease the required number of subsequent orthopedic operations.
  • Although it is performed on the spinal cord, if this procedure is done in early childhood, it can contribute to secondary improvement of speech ability, depth sensitivity and control of the upper body and hand function.

The Operation

Selektive dorsale Rhizotomie Abb.1
Selektive dorsale Rhizotomie Abb.2
Selektive dorsale Rhizotomie Abb.3

Selective dorsal rhizotomy (SDR) is a microsurgical procedure.

Contrary to all previous surgical approaches, it can be done with minimal access to the spinal column over a approx. 5 cm section. After the spinal canal is reached, the dura mater, common sheath of the nerve roots and the spinal cord, is opened. Here we can see the origin of all the nerves extending into the lower half of the body in the spinal cord.

The portions of the nerve roots responsible for transmitting spasticity are now isolated with small plastic films. Their function is measured using small electrical impulses. The response signal is evaluated according to the criteria defined by the specialist in charge of intraoperative neuromonitoring, Dr. rer. medic. Simone Wolter. On the basis of this evaluation, the surgeon cuts all the fibers sending an especially high intensity of spastic impulses and leaves the less affected fibers intact in order to maintain the functionality of all the roots.

Since up to 60 measurements are necessary, the procedure can take several hours. Thereafter the dura is sutured and the wound closed in layers. The skin is cosmetically sutured with self-dissolving thread.

Risk

Every multi-hour procedure on a child carries with it both surgical and aesthesia-related risks. In general, however, the risk is relatively low. Prior to an operation, all risks are discussed with the child and his or parents in detail.

After the Operation

After the operation, the child is placed in an observation ward with a balloon catheter and an infusion system for 24 hours. There he or she receives pain medication and muscle relaxants. Thereafter the catheter is removed and the child is taken back to his or her admission room.

After 2 days of strict bed rest, an assisted attempt to sit up in a wheel chair can be made for about 1 hour. Afterwards, mild physiotherapy begins. The child is discharged a few days later.

Muscle spasms may disturb the child's sleep at night. If this occurs, the child can be administered a muscle relaxant at night.

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The Rhizotomy Program

Rhizotomy is not just an operation - it is a comprehensive program. The selection and preparation of the patients, administration of anesthesia and pain therapy, physical and psychological care by pediatricians, adaptation of walking aids and transition to everyday life outside the hospital all require an interdisciplinary team of specialists. This team was formed under the aegis of our pediatric neurologists at the Center for Social Pediatrics at Charité Hospital.

Rehabilitation

Spasticity limits arbitrary movement of the legs and thus impairs the strengthening of the leg muscles. The legs thus not only become stiff, they also stay weak. With the disappearance of spasticity, the patient initially feels his or her preexisting leg weakness especially strongly. This is because the muscle development which is first made possible through the operation takes time. It can take several weeks or months until the child recovers his or her previous walking ability, now with significantly reduced spasticity. Then comes the expected improvement exceeding the child's previous ability: a more fluid gait with longer steps can be achieved.

For the rapid and targeted rebuilding of complex movement processes and simultaneous training of cerebral performance (speech, concentration), a period of treatmetn in a specialized rehabilitation clinic is recommended.

Literature

  • Adriano Ferrari, Giovanni Cioni: Infantile Cerebral Palsy - Spontaner Verlauf und Orientierungshilfen für die Rehabilitation (Infantile Cerebral Palsy - Spontaneous Course and Orientation Aids for Rehabilitation.
  • R. Holtz: Therapiehilfen und Alltagshilfen für zerebralparetische Kinder (Treatment and Everyday Aids for Children with Cerebral Palsy).
  • B. Bobath, K. Bobath: Die motorische Entwicklung bei Zerebralparesen (Motor Development in Cerebral Palsy.)
  • R. Feldkamp, D. van Aufschnaiter, J.U. Baumann: Krankengymnastische Behandlung der Infantilen Zerebralparese (Physiotherapeutic Treatment for Infantile Cerebral Palsy).
  • M. Feldkamp: Das zerebralparetische Kind. Konzepte therapeutischer Förderung (Children with Cerebral Palsy. Therapeutic Concepts).
  • F. Heinen (Ed.): Botulinumtoxin bei Kindern mit Cerebralparese (Botulinum Toxin for Children with Cerebral Palsy).
  • Therapieverfahren bei infantilen Cerebralparesen (Materialsammlung) Bezugsadresse (Treatment for Children with Cerebral Palsy (Collection of Sources) Reference Address).
  • Freeman Miller, Steven J. Bachrach, Stephen J. Bachrach: Cerebral Palsy: A Complete Guide for Caregiving. For family members and health care professionals.

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